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Fiscal Year 2003 Performance Plan

Budget and Program Aggregation

The AHRQ GPRA annual performance report and plans are aligned with the Agency's three budget lines:

Research on Health Care Costs, Quality, and Outcomes,

Medical Expenditure Panel Survey, and

Program Support.

The first two budget lines are where Agency programs are funded. The goals associated with each of the budget lines represent core activities funded in each. The following two tables illustrate how the GPRA goals are aligned with the AHRQ budget lines.

Beginning in FY 2003, AHRQ has redesigned our strategic management system and revised our GPRA goals to align more closely with the Agency's strategic plan. Table 2 shows this revision and realignment; Select for FY 2001-2002 framework along with the FY 2003 framework.

We believe that this realignment will not only help us determine how well the basic knowledge which forms the core of AHRQ's work provides information which can be turned into actions by those who make clinical decisions, purchasers and providers who make decisions about what services to use, pay for and how to structure those services, as well as by policy makers but will allow us, in time to answer the question, "What difference has AHRQ sponsored research made?"

2.1.1 Performance Goal: To have measurable improvement in the type of delivery system or processes by which care is provided and their effects on health care outcomes.

Program Description and Context

At its most basic level, providing high quality health care is doing the right thing, at the right time, in the right way, for the right person. The challenge that health care providers and health systems managers face everyday is knowing what the right thing is, when the time is right, and what the right way is. Patients and their families are also faced with making choices about treatments and care settings with little information on the relative quality, risks and benefits available to them.

One of the most important priorities of AHRQ is to translate and disseminate the findings of research supported by the Agency into tools and information that can be used by its customers to make good health care decisions and to improve the outcomes of care. The research supported by AHRQ has historically concentrated on conditions that are common, costly, and for which there is substantial variation in practice. This research includes many of the conditions that represent major expenditures for Medicare and Medicaid. AHRQ's research attempts to reduce inappropriate variation and provide our health care decision maker with information on what care is appropriate, which clinical services work best in what circumstances and for which patients, how much is enough, and what resources are used to provide it. Outcomes research also attempts to help decision makers understand the implications of structural and financing changes in the health care system on the outcomes of care delivered in the system.

Outcomes and effectiveness research seeks to understand the end results of particular health care practices and interventions. Outcomes include effects that people experience and care about, such as change in the ability to function. In particular, for individuals with chronic conditions—where cure is not always possible—end results include quality of life as well as mortality. By linking the care people get to the outcomes they experience, outcomes research has become the key to developing better ways to monitor and improve the quality of care. Supporting improvements in health outcomes is a strategic goal of the Agency for Healthcare Research and Quality.

Strategies to Improve Health Outcomes:

At the requested level, AHRQ's programs will assist with Secretarial Initiatives, particularly in the area of chronic illness, such as diabetes and asthma. Comprehensive primary care services can reduce the morbidity associated with these illnesses. Hospital admission rates for "ambulatory care sensitive conditions" serve as a marker for both impaired access to primary care and suboptimal quality of primary care delivered. Disparities in admission rates for racial and ethnic minorities and low-income populations have been well documented.

Programs that support AHRQ's efforts to improve the outcomes include: Centers for Education and Research on Therapeutics (CERTS), Evidence-based Practice Centers (EPCs), U.S. Preventive Services Task Force (USPTF); National Guidelines Clearinghouse (NGC) and Patient Outcomes Research Teams (PORTs).

Centers for Education and Research on Therapeutics (CERTS):

The CERTS program is a national initiative designed to increase the awareness of the benefits and risks of new, existing, or combined uses of therapeutics through education and research. The CERT's program grew out of recognition that physicians need more information about the therapies they prescribe. Although information is available through the pharmaceutical industry, continuing medical education programs, professional organizations, and peer reviewed literature, comparative information about the risks and benefits of new and older agents and about drug interactions is limited.

The research conducted by the CERT's program contributes to improving the health of Americans by increasing awareness of both the uses and risks of new drugs and drug combinations, biological products, and devices as well as of mechanisms to improve their safe and effective use; providing clinical information to patients and consumers; health care providers; pharmacists, pharmacy benefit managers, and purchasers; health maintenance organizations and health care delivery systems; insurers; and government agencies; and improving quality while reducing the cost of care by increasing the appropriate use of pharmaceuticals and biological products and devices and by preventing their adverse effects and the consequences of these effects (such as unnecessary hospitalizations).

Evidence-based Practice Centers (EPCs):

As the lead Federal agency for enhancing the quality, appropriateness, and effectiveness of healthcare services and access to such services, AHRQ conducts and funds research that develops and presents evidence-based information on healthcare outcomes, quality, cost, use and access. Included in AHRQ's legislative mandate is support of syntheses and widespread dissemination of scientific evidence, including dissemination of methods or systems for rating the strength of scientific evidence. These research findings and syntheses assist providers, clinicians, payers, patients, and policymakers in making evidence-based decisions regarding the quality and effectiveness of health care.

As a part of its charge to improve the quality and effectiveness of health care through the development of state-of-the-art health care information, and to respond to significant changes within the health care industry, AHRQ established 12 Evidence-based Practice Centers in 1997. AHRQ has become a science partner with private and public-sector organizations in their efforts to improve the quality, effectiveness and appropriateness of clinical practice. Since 1997, the EPCs have conduced more than 80 systematic reviews and analyses of scientific literature on a wide spectrum of topics, incorporating the results and conclusions into evidence reports and technology assessments.

The EPC program contributes to AHRQ's goal of improving the health of the American public by producing synthesis of clinical research findings through systematic methods for searching, reviewing, and evaluating the clinical literature. Evidence reports and technology assessments can be used by systems of care, professional societies, health plans, public and private purchasers, States, and other entities as the scientific foundation for development and implementation of their own clinical practice guidelines, clinical pathways, review criteria, performance measures, and other clinical quality improvement tools, as well as for formulation of evidence-based policies related to specific health care technologies.

U.S. Preventive Services Task Force (USPSTF):

Premature deaths and disabilities due to preventable causes continue to extract a large toll in the United States. Health care providers and health care organizations play an essential role in national prevention efforts, by delivering effective vaccines, screening patients for early disease or risk factors, counseling about health lifestyles, and prescribing preventive medications. Despite steady progress in the delivery of effective preventive care, important gaps remain—as of 1998, more than one third of women over 50 had not had a mammogram and breast exam in the last 2 years to screen for breast cancer, and more than a third of older adults had not received a flu shot that year. Inequities in preventive care also contribute to the disparities in the health of specific populations, such as racial and ethnic minorities, the elderly, and the poor and disabled.

The U.S. Preventive Services Task Force (USPSTF) and Put Prevention Into Practice (PPIP), two major programs at AHRQ, make significant contributes to the Department of Health and Human Services prevention activities. The U.S. Preventive Services Task Force, first convened in 1984, is charged with systematically reviewing the evidence of the effectiveness of a wide range of clinical preventive services, including screening tests, counseling, immunizations, and chemoprophylaxis. The Put Prevention Into Practice program then works to translate information from USPSTF reports into a format that meets the needs of a wide variety of patients, clinicians, health plans, and health care purchasers.

National Guideline Clearinghouse (NGC):

The National Guideline Clearinghouse is a publicly available, web-based database of evidence-based clinical practice guidelines and related documents. Updated weekly with new content, the NGC is a partnership between AHRQ, the American Medical Association (AMA) and the American Association of Health Plans (AAHP) Foundation.

In its two years of operation, the NGC has become a resource for physicians, nurses and other health care professionals as well as purchasers and policy makers. Individual physicians and other clinicians can review and use the NGC in clinical decision making and patient counseling; health care organizations and integrated delivery systems can use information accessible through the NGC to adopt or adapt guidelines for their networks; medical specialty and professional societies can use NGC resources in their own guideline development efforts; employers and other large purchasers can use information from the NGC to assist them in making health care benefits purchasing decisions; educational institutions can incorporate information accessible through the NGC into their curricula and continuing education activities; and State and local governments can use the NGC in their quality assurance and program oversight efforts.

Patient Outcomes Research Teams (PORTs)

Beginning in 1989, the AHRQ (formerly the Agency for Health Care Policy and Research) funded a set of ambitious research projects known as patient outcomes research teams (PORTs). These 14 projects were succeeded, starting in 1993, by a "second generation" of projects known as PORT-II. Together, AHRQ's PORTs and PORT-IIs represent a total investment of more than $100 million to answer critical questions about the effectiveness and cost-effectiveness of available treatments for common clinical conditions. A recent article by researchers from several PORTs, as well as Carolyn M. Clancy, M.D., Director of AHRQ's Center for Outcomes and Effectiveness Research, describes the purpose and accomplishments of the PORTs.

The PORTs were designed to take advantage of readily available data and to focus on common clinical conditions that are costly to the Medicare and Medicaid programs and for which there is regional variability in outcomes and use of resources. The PORTs are made up of a multidisciplinary team of researchers ranging from health economists and clinicians to quality-of-life experts and epidemiologists. PORT investigators were instructed to answer the following questions: What works and at what cost? For which patients or subgroups of patients? When? Why is there variation in the use of treatments? What can be done to reduce inappropriate variation? From whose perspective—i.e., the patient is the ultimate judge of effectiveness? Is there a potential for development and use of patient-reported outcome measures?

PORT researchers advanced the methods and applications of outcomes and effectiveness research, that is, the examination of the end results of medical interventions when applied to patients in everyday practice. Effectiveness studies often are designed to monitor patients over time, wherever they get their care, and to chart the outcomes of that care. PORT researchers use Medicare and Medicaid data and data from insurance claims and other large administrative databases to characterize patterns of care, develop general and disease-specific outcome measures, and disseminate important outcome information to patients and physicians to reduce inappropriate practice variation and improve outcomes.

The three outcome measures selected represent common problems encountered in primary care and allow monitoring for children (asthma), the elderly (pneumonia and influenza), and high-risk infants (respiratory distress syndrome). For each condition there is evidence that interventions can reduce hospitalization rates. These conditions were chosen because reduction of morbidity can be obtained by coordination of community preventive services, public health interventions, clinical preventive services and primary care.

Interventions that improve access to and quality of care in population groups at high risk for avoidable hospitalizations and coordination of these efforts with community-based public health activities have the potential to reduce the disparities identified here. The national goal of a 25% reduction in avoidable hospitalizations for these conditions can be achieved through targeting these high-risk populations. The objective is to reduce the need for admission, and therefore the morbidity and costs associated with hospitalization, through improved primary care and preventive services.

Key Outcomes Improving Health Outcomes, FY 2003

Reduce by 5% the hospitalization rates for pediatric asthma

Reduce by 5% the immunization-preventable pneumonia or influenza in patients 65 and older.

Decrease by 5% the number of premature babies who develop Respiratory Distress Syndrome (RDS).

Program Outputs Needed to Achieve Expected Results

At the budget level proposed in the President's Budget, AHRQ will maintain funding for Translating Research Into Practice grants and contracts. At this level, expiring grants are not continued and the dollar amount reduction will be spread across non-patient safety and training grants.

Maintain the number of synthesis reports generated on research findings and practical applications on Agency priority topics at FY 2001 levels.

Report on impact of 5 uses of AHRQ-sponsored evidence reports, systematic evidence reviews, technology assessments, and the National Guideline Clearinghouse for which Federal or other government agencies, professional associations, or other private healthcare organizations are measuring or assessing the impact on clinical practice and/or patient outcomes.

Improve the evidence available to Federal and other direct care providers, professional associations, and other healthcare organizations to increase evidence-based practice and enhance health outcomes and quality.

AHRQ will use the following indicators to report success in this area

Using data found in HCUP, track the number of premature infants who develop RDS

Using data found in HCUP, track the number of patients 65 and older hospitalized for immunization-preventable pneumonia or influenza

Using data found in HCUP, track the number of children hospitalized for complications related to pediatric asthma

Track the number of research findings that have been translated into practice

Track the use of evidence by increasing the more effective partnerships with those who nominate topics for the EPCs, etc)

2.1.2 Performance Goal 2: To have measurable improvement in the quality and safety of healthcare for Americans

2.1.2.1: Measuring Improvements in Quality Program Description and Context

The United States has many of the world's finest health care professionals, academic health centers, and other research institutions. Patients sometimes receive excessive services that undermine the quality of care and needlessly increase costs. At other times, they do not receive the services that have proven to be effective at improving health outcomes and even reducing costs.

A recent Institute of Medicine (IOM) report states "Quality problems are everywhere, affecting many patients. Between the health care we have and the care we could have lies not just a gap but a chasm." In this report, the IOM proposes 13 recommendations to build a stronger healthcare system over the next decade.

One of AHRQ's strategic goals is to strengthen the quality of healthcare measurement and track improvements in the care available to Americans. To achieve this goal AHRQ has invested in the development and testing of measures of quality, as well as studies of the best ways to collect, compare and communicate these data, and identifying and widely disseminating effective strategies to improve quality of care. To facilitate the use of this information in the health care system, the Agency focuses on research that determines the most effective ways to improve health care quality, including promoting the use of information on quality through a variety of strategies, such as information dissemination and assessing the impact of health care organization and financing.

Meeting the needs of consumers, practitioners, and policymakers will depend in part on the availability of valid and useable measures of the quality of care. AHRQ will translate the findings from health services research, effectiveness studies, technology assessments, and clinical practice guidelines into quality of care measures and methods for everyday settings. Basic research will develop more refined measures and improvement strategies. Applied research and development will test the validity and reliability of the measurement instruments and facilitate their use in different population subgroups (such as minority groups, chronically ill, disabled, elderly, and children) and care settings. Demonstration projects will assess the use of measures and tools in performance management systems and quality improvement activities.

Strategies to Improve the Quality of Health Care

The National Quality Report

The Agency's reauthorization calls for the development of a national report on the quality of healthcare in the U.S. In developing this report, the Agency is called on by the legislation to expand the Medical Expenditure Panel Survey (MEPS) to collect information on quality. In addition, the Agency is charged with assuring coordination with the private sector in the development of the report. In its report on AHRQ's reauthorization, the Senate Health Education Labor and Pension Committee provided the following guidance:

"Beginning in FY 2003, the Secretary, acting through the Director, is to submit an annual report on national trends in health care quality, drawing upon the enhanced MEPS survey and other available data. The Committee expects the Agency to use a variety of measures to develop this annual picture of how health care quality is faring. The legislation directs the Agency to take into account any outcomes measurements generally collected by private sector accreditation organizations to assure that the reported information is not inconsistent with what is being collected through other programs. The committee hopes that this annual report will provide an opportunity for quality performance comparisons."

The Agency's coordination of the development of a National Healthcare Quality Report is also responsive to the President's Quality Commission report, which concluded, "The lack of comprehensive information on the quality of American health care is unacceptable." Finally, the recent Institute of Medicine's Commission on medical errors called for a national report on progress on that issue. These mandates envision a report that goes beyond a compilation of available data and statistics to provide a framework for those public and private entities with an interest in improving the quality and safety of patient care.

HCUP Quality Indicators:

Health care decision makers need user-friendly data and tools to help them assess the effects of health care program and policy changes, accurately measure outcomes, community access to care, utilization and cost of care as well as to guide future health care policy making.

To meet this need, AHRQ has developed a set of Quality Indicators (QIs), which use hospital administrative data to highlight potential quality concerns, identify areas that need further study and investigation, and track changes over time. These indicators represent a refinement and further development of the Quality Indicators developed in the early 1990's as part of the Healthcare Cost and Utilization Project (HCUP).

The AHRQ QIs are a set of quality indicators that have been organized into three modules: Prevention, Inpatient and Patient Safety QIs.

Using these modules in FY 2003, hospital and hospital systems can use AHRQ QIs to help answer questions such as:

How does our hospital's cesarean section rate compare to the State or Nation?

Do other hospitals have similar mortality rates following hip replacement?

How does the volume of coronary artery bypass graft in my hospital compare with other hospitals?

State data organizations and community health partnerships can use AHRQ QIs to ask questions that provide initial feedback about clinical areas appropriate for further, more in-depth analysis, such as:

What can the pediatric AHRQ QIs tell us about the adequacy of pediatric primary care in our community?

How does the hysterectomy rate in our area compare with the State and national average?

State hospital associations can use the AHRQ QIs to do quick hospital quality and primary care access screens. Other potential users include managed care organizations, business-health coalitions, state data organizations, and others poised to begin assessments using hospital discharge data to answer questions such as:

Can we design community interventions in areas surrounding hospitals that have higher rates of diabetes complications?

Which Quality Indicators can be incorporated into performance management initiatives for our member hospitals?

Finally, Federal policymakers can use the AHRQ QIs to track health care quality in the United States over time and to assess whether health care quality is improving, for example:

How does the rate of coronary artery bypass grafts vary over time and across regions of the United States?

What is the national average for bilateral cardiac catheterization (a procedure generally not recommended) and how has this changed over time?

Translating Research Into Practice (TRIP)

Translating research findings into sustainable improvements in clinical outcomes and patients' outcomes remains a substantial obstacle to improving the quality of health care in America. What has been learned in the research setting is often not incorporated into daily clinical practice. To address this gap, in September 2000 AHRQ funded 13 new projects to evaluate different strategies for translating research findings into clinical practice. The aim of these 3-year cooperative agreements is to identify sustainable and reproducible strategies to:

Help accelerate the impact of health services research on direct patient care

These new projects join 14 others funded in 1999 as part of a major initiative by AHRQ to close the gap between knowledge and practice-between what we know and what we do-to ensure continuing improvements in the quality of the Nation's health care.

The 14 studies supported in the initial phase of the TRIP initiative address a variety of health care problems, primarily through randomized controlled trials. These studies, which represent important prototypes of what is possible under ideal circumstances, generally require an elaborate strategy for superimposing data collection on the demands of routine practice.

The second phase of this initiative, TRIP-II is aimed at applying and assessing strategies and methods that were developed idealized practice settings or that are in current use but have not been evaluated. Furthermore, increased demands for accountability in health care, including reporting of clinical performance using standardized quality measures, have created a sense of urgency regarding improvement within health care organizations. With this as a basis, TRIP-II focuses on implementation techniques and factors—such as organizational and clinical characteristics—associated with successfully translating research findings into diverse applied settings, including AHRQ sponsored Practice Base Research Networks (PBRNs).

Consumer Assessment of Health Plans (CAHPS®)

Consumer Assessment of Health Plans makes available consumers' ratings of the quality of care and services they get from their health plans. This information is used by other consumers to make informed choices among health plans, by health care purchasers—such as employers or Medicaid programs—to select plans to offer their employees or beneficiaries, and by plans for quality monitoring and improvement. CAHPS® already has been used by more than 20 states, 10 employer groups and a wide range of health plans and companies. For example, CAHPS® was adopted by the Office of Personnel Management for use by the Federal Employees Health Benefits Program to survey Federal employees and report the findings to help about 9 million Federal Employees choose health plans during the federal open season. CAHPS® also merged with the HEDIS (Health Plan Employer Data and Information Set) Member Satisfaction Survey and will be used by the National Committee for Quality Assurance to evaluate and accredit managed care plans for 40 million Americans. Finally, the Centers for Medicare and Medicaid Services (CMS) has used a specially developed version of CAHPS® to survey over 130,000 Medicare enrollees in managed care plans. The results of this survey, which was released in February 1999, was available to help CMS's 39 million beneficiaries who will be selecting a health plan.

These, and other successful uses of CAHPS®, is a testament to the importance of sustained basic and applied health services research in producing practical information for everyday health decision making.